Redeeming behaviours: How incentive programs can improve adherence
*Joan Wharf Higgins of the School of Exercise Science, Physical & Health Education at the University of Victoria outlines the latest research showing how incentives impact adherence ra*
By on Jan 31, 2011Joan Wharf Higgins of the School of Exercise Science, Physical & Health Education at the University of Victoria outlines the latest research showing how incentives impact adherence rates
We live in an era in which chronic health issues are commonplace and increasingly dominate our healthcare attention and resources, with an estimated economic burden of over $80 billion each year.
To turn the tide, layered and coordinated initiatives at the population level are needed that educate, motivate, and support individuals to embrace healthy living.
Low adherence to medical regimens is very common, with estimates that between 20% to 50 percent of patients do not take their medication as prescribed.
For example, adherence to pharmacotherapy for high blood pressure has been estimated by the World Health Organization to be between 50 and 70 percent, suggesting that poor adherence is a primary cause for failure to control hypertension.
The issue of non adherence is particularly relevant for persons living with chronic conditions compared to patients with more acute illnesses; adherence rates tend to drop after the first six months of therapy and often even earlier.
Identifying new interventions is critical to curbing low adherence rates, including the use of incentives and interactive computer-based health communication applications that combine health information with behavioural strategies.
The science of behaviour change
Despite an initial reluctance to give money or rewards to motivate change or enhance complianceshould we reward people for doing things they should be doing anyway?early investigations found financial and other incentives to be effective in increasing adherence.
A 2004 review of 23 studies seeking to change behaviours related to exercise, smoking, and/or body weight observed a short-term positive effect from the use of incentives 72 percent of the time.
The review also found minimal evidence to support a dose response; the higher the value of the incentive, the higher the behavioural response to the incentive.
The science of behaviour change has found success with the use of technology, including Web-based health education, counselling, and online self-monitoring and support groups for improved practices in diet, physical activity, smoking, and chronic diseases.
Research has found that adults may prefer an online environment for its ease of access, convenience, anonymity, and non-stigmatized environment related to seeking health information rather than engaging in face-to-face clinical visits.
One review of the literature identified three primary types of interventions for improving adherence to prescribed medicine: behavioural approaches, education or information giving, and healthcare professional involvement.
Typical of behaviour approaches are drug compliance aids, blister packaging, reminder charts, and pill boxes.
Of course, patients should be informed adequately about their condition and treatment so that they retain the information and are able to make positive changes.
However, educational interventions alone have been found to be largely unsuccessful.
Complex interventions that combine education with other strategies are more efficient and can increase adherence by as much as 5 to 41 percent.
Pharmacist-led interventions studies report mixed results but overall suggest that their involvement is beneficial to patient adherence. (For more on pharmacists and adherence, see The pharmacist's role in patient adherence and The pharmacist as an ally in patient adherence.)
Behaviour change recommendations suggest that in order to improve adherence, changing the situation or context may be more promising than changing the patient.
Research investigating the effects of financial and economically-related rewards for improving physical activity levels provides support for the use of such incentives.
Indeed, a recent review of computer-tailored interventions to enhance physical activity levels found that those studies providing incentives demonstrated a participant retention rate of 80 percent or higher.
One study of obese African-American women found that offering a free gym membership was likely a key ingredient in the success of the recruitment, intervention delivery, and retention of this high-risk, underserved, and understudied population.
The study found that the intervention produced modest short-term improvements in body composition, but the economic incentive of a free one-year gym membership was a more potent intervention than the education and social support condition tested.
The power of incentives
Research in 2007 indicated the potential of financial incentives (in the form of registration reimbursement) on attendance and adherence to a weight-loss program.
(For more on incentives related to employee productivity and performance, see Do incentive schemes work?.)
While the studys program participants did not demonstrate significant weight loss compared to a control group, there was a strong association between attendance and weight loss for those in the intervention group promised reimbursements based on reaching weight loss goals.
In a randomized controlled trial offering a free prepared meal and weekly counselling intervention, greater weight loss and weight loss maintenance was demonstrated at two years in 407 overweight or obese women compared to usual care.
For smoking cessation, a randomized trial in a general sample of Dutch smokers examined the effects of full financial reimbursement for purchasing a pharmacological treatment (chewing gum, patch, tablet, sublingual tablet and inhaler), behavioural counselling (written advice, telephone or face-to-face counselling), or a combination of the two.
To receive reimbursement, study participants were required to send their receipt and two statements of personal contact with a healthcare professional to the health insurance company.
Results showed that participants from the intervention group had a 2.9 times higher chance of using smoking cessation treatment during the six-month study period compared with participants from the control group and were 1.4 times more likely to have quit smoking.
Evaluating the impact of financial rewards for smoking cessation, 179 smokers were randomized into incentive and non-incentive groups.
While both groups were provided free instruction in the management of smoking triggers, relapse prevention, and stress management techniques as well as counselling, the incentive group was also offered $20 for each class attended and $100 if they quit smoking 30 days following the program.
Self-reported smoking cessation was confirmed with urine cotinine tests.
The incentive group had significantly higher rates of program enrolment and quit rates at 75 days.
At six months, however, quit rates in the incentive group were not significantly higher than in the control group.
The researchers concluded that modest financial incentives can produce significantly higher rates of smoking cessation program enrolment and completion and short-term quit rates, while incentives for longer-term cessation need to be explored.
Incentives and the long term
Indeed, a review examining the impact of competitions and incentives on long-term smoking cessation, as well as the relationship between incentives and participation rates, found that early success tended to dissipate when rewards were no longer offered.
However, rewarding participation and compliance in contests and cessation programs may have more potential to deliver higher absolute numbers of quitters.
In another recent US trial, the largest to date, employees were offered up to $750 for completion of a smoking cessation program as well as abstinence at six and 12 months, with the largest sum ($400) deliverable for 12 months abstinence.
This is the first trial to show that personal financial incentives can lead to significantly higher sustained quitting at one year.
Other incentive-based employee programs have also proved effective.
Detailed retrospective analyses of employer-based disease management programs found that use of gift cards/certificates, cash, and reductions in out-of-pocket health expenses or lower premiums demonstrated a direct relationship between level of employee participation/completion and the amount of the incentive.
Cash incentives greater than $50 were observed to be the most efficient.
A systematic review of 38 studies on the effectiveness of adherence interventions between 1990 and 2005 found that behavioural interventions that offered patients cash, gifts, or vouchers significantly improved their medical adherence in 10 of 11 studies.
Adding a twist to the reward structure, another study investigated the feasibility and effectiveness of daily lottery incentives on Warfarin adherence in a cohort study of patients at risk of thromboembolism.
The researchers found that the lottery-based financial incentive coupled with a simple reminder (a chime that was sent to patients Med-eMonitors) substantially improved the rate of non-adherence to Warfarin.
The researchers went on to say that daily lotteries may be more effective than one-time payouts.
Drawing on the behavioural economics literature on incentives, this study showed that small rewards can have great incentive value, people are motivated by past rewards and the prospect of future rewards, and that people are particularly attracted to small probabilities of large rewards.
Rewards for life
In their comprehensive review of the literature on incentives and behaviour change, Sutherland and colleagues concludes that incentives, even rather small ones, can influence health behaviours, including both improving patients adherence and facilitating voluntary behaviour change.
This is especially true when studies for behaviour are incentivized over the longer term rather than for shorter timelines.
For the behaviour to persist, the incentives either need to be continued or reinforced through intermittent rewards.
Because practices such as being active, eating healthfully, and giving up smoking rarely bestow immediate, inherently enjoyable activities, even highly motivated individuals can have difficulty remaining adherent.
Offering rewards or incentives as extrinsic motivators may bridge the time needed to internalize the values and benefits of healthy living.
The best application of incentives is to use them to attract and engage people through sustained extrinsic rewards, so that they can connect, realize, and appreciate their intrinsic motivators to help them sustain lifelong health practices.
The BestLifeRewarded (BLR) loyalty rewards program is designed to do this for Canadians.
BLR leverages the success of recognized and established consumer loyalty programs such as travel reward miles and grocery store chain points cards to reward healthy living, including healthier eating, being more physically active, quitting smoking, taking prescribed medications, and tracking blood pressure.
BLR members can exchange their accumulated points for tangible rewards in the form of gym memberships, healthy cookbooks, blood pressure monitoring devices, consultations with registered dieticians, or donations to selected health-related charities.
(For more on charitable giving and adherence, see Leveraging altruism to improve compliance.)
Points are earned from engaging in one or more of the healthy practices or for improving health education and literacy through the site, tracking their healthy behaviours, or signing up for daily reminders, such as taking the stairs instead of the elevator or taking medication as prescribed.
This is an edited extract from Redeeming Behaviours: The Influence of Incentive-Based Programs on Health Adherence and Behaviour Change by Joan Wharf Higgins, the School of Exercise Science, Physical & Health Education, at the University of Victoria, with contributions from Jenny Scott, M.A. (Simon Fraser University) and Steven Giovannini, B.Sc. (University of Victoria).
To download the complete whitepaper, go to the Cookson James Loyalty site.
For more on incentives and adherence, join the sector's key players at Patient Adherence, Communication & Engagement Europe on May 31-June 1 in Berlin.